The surgeon has used the MIS approach for 6 years, and over time, it has become their standard approach for all resections, regardless of pathology unless there are specific patient or anatomical factors that the Dr. feels would add too much risk. For example, multiple prior abdominal surgeries, limiting co-morbidities, or combined venous/arterial involvement. Early in this surgeonÃ¢ï¿½ï¿½s experience, case selection was much more selective. Over time and with growing experience and comfort, factors such as BMI, pathology, neoadjuvant therapy were no longer limiting factors. The team has done over 12 MVR with either SMV or Portal vein resection/reconstruction so vein involvement alone is no longer an automatic exclusion.

The decision for, and choice of stenting is largely dependent on duct size. With that said, Dr. Shah used a stent in the majority of cases, as it facilitates the suturing of the duct mucosa. The gland texture certainly plays a role in MIS as well as open reconstruction. With very soft glands and ducts of <3mm, Dr. Shah often use an intussucepted PJ anastomosis, which is also very feasible with MIS. In their series of >100 MIS Whipples, approximately 75% are duct to mucosa PJ, and 20% intussucepted PJ, 5% PG. This surgeon routinely leaves one 19fr blake drain.

Resectional equivalence has been well demonstrated by this group, as well as many others, oncologic equivalence needs further long term data, but appears to be equivalent as well. There has been extensive reporting from multiple groups worldwide (Kendrick, Asbun, Palanivelu, Gumbs, Dulucq, as well as our own,presented at SSAT)) demonstrating that quality of resection (margins, nodes, etc ) can be equal or better. Other peri-operative parameters have a similar profile to MIS applications in the GI tract, namely, lower EBL, shorter LOS ( albeit by 1-2 days), and faster return to functional status. OR times are invariably longer. There is clearly a significant and multi-modal learning curve, with variable conversion rates throughout that curve, as in most advanced MIS procedures. In Dr. ShahÃ¢ï¿½ï¿½s experience, most conversions have been due to either need for vascular control or vascular involvement. There is little data on overall DFS and OS in resections for adenoca, but it does not appear to be significantly different as yet. Interestingly, there does appear to be a higher rate of both initiation and completion of adjuvant therapy after Lap Whipple compared to open, and an earlier onset to adjuvant as well. Whether that translates to improved cancer related outcomes remains to be seen. Anecdotal evidence suggest that the OS is largely similar, and reflects the underlying biology of the disease more than any potential benefit that the MIS approach can provide from reduced physiological impact and preserved immune response. Certainly for non-adenoca indications such as NET, SPEN, IPMN, etc, the MIS approach is even more appealing as the resections are often more straightforward.

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